An Independent Licensee of the Blue Cross and Blue Shield Association

450 Riverchase Parkway East P.O. Box 995Birmingham, Alabama 35298-0001

ADDRESS SERVICE REQUESTED

• Electronic Payments

• W-2 Reports Now Available on GroupAccess

• Affordable Care Act – Health Programs and Activities

• Affordable Care Act – Transgender Services Benefit

• Determining 6055-6056 Reporting: Employer Shared Responsibility

• Reminder: Employer Payment Plans and Market Reforms

• New Healthcare Reform Preventive Mandates

• BlueCard Worldwide Program Name Change

Inside this issue…D E C E M B E R 2 0 1 6

Group Updatefor EMPLOYERS

DECEMBER 2016

Electronic Payments

Take the hassle out of mailing your monthly payments to Blue Cross by choosing electronic payments. We offer several options.

Automatic monthly payments

• You can set up automatic monthly payments to be deducted from your group’s checking account by completing and signing the CAD-102 form. Email it to GroupEnrollPayments@bcbsal.org or log in to GroupAccess.

• Drafts are deducted from your group’s checking account on the first of every month.

• Your monthly invoice will indicate if you are set up for automatic monthly payments.

One-time e-check payments

• You can make a one-time e-check payment by completing and signing the CAD-102 form. Email it to GroupEnrollPayments@bcbsal.org or log in to GroupAccess.

Online bill payment

• You can set up automatic monthly payments or make one-time payments through your group’s financial institution using online bill payment.

• Make sure you enter your group’s entire bank account number and the correct amount of your invoice when setting up online bill payment.

• If the invoice amount changes, it is your responsibly to update the draft amount with your group’s financial institution.

Group Update available on GroupAccessGroup Update is available on GroupAccess. Just sign in at AlabamaBlue.com/employers and look under “What’s New.” You can find the current issue and past issues back to 2006.

Important Date for Calendar Year Group Health Plans: December 31, 2016 • This is the last day for employers to give members the annual Women’s Health and Cancer Rights Act notice. Blue Cross has a sample notice that your group may use.• This is the last day for employers to give employees notices of premium assistance under Medicaid or the Children’s Health Insurance Program. Blue Cross does not have sample notices for groups. There is a form notice that your group may use on the Centers for Medicare and Medicaid Services website.

W-2 Reports Now Availableon GroupAccess

W-2 reporting of employer-sponsored health coverage is now available on GroupAccess. The Excel formatted reports can be downloaded by accessing the Group Reports link located in the Reports section of GroupAccess. The report shows billed premiums. If you have questions, please contact your group enrollment representative. For more information regarding this Affordable Care Act requirement, please visit:

https://www.irs.gov/Affordable-Care-Act/Form-W-2-Reporting-of-Employer-Sponsored-Health-Coverage

What are the required administrative practices and when do these come into effect?The final rule requires all covered entities to post a notice of nondiscrimination and taglines in the top 15 foreign languages in the relevant state on their website, buildings with access to the public, and significant communications to the public, such as patients and plan members.

The notice and taglines tell people about the availability of free foreign language assistance and accessibility services. Covered entities with 15 or more employees are also required to have a nondiscrimination grievance procedure. For small size significant communications, covered entities are permitted to use a short discrimination statement and the top 2 foreign languages spoken in the relevant state.

Covered entities are required to make electronic and information technology accessible to individuals with disabilities. Covered entities must meet this requirement unless it would result in undue financial and administrative burdens or a fundamental change in the nature of the health programs or activities.

Covered entities must comply with the notice and tagline requirements above on or by October 16, 2016. All other administrative practices of covered organizations had to be in compliance with the final rule on July 18, 2016.

What are the health plan requirements and when do these come into effect?Under the final rule, sex discrimination includes, but is not limited to, discrimination on the basis of pregnancy, gender identity, and sex stereotyping. A covered entity cannot, on the basis of pregnancy, gender identity, and sex stereotyping:

• Deny, cancel, limit, or refuse to issue or renew any health-related coverage;

• Deny or limit coverage of a claim, or impose additional cost sharing or other limitations or restrictions;

• Employ marketing practices or benefit designs that discriminate; or,

• Have categorical coverage exclusions or limitations for all health services related to gender transition.

Who is impacted by Section 1557?The final rule applies to the following covered entities:

• All underwritten health plans offered by health insurers that participate in the Health Insurance Marketplace or the Medicare Advantage/Prescription Drug programs, such as Blue Cross and Blue Shield of Alabama;

• All administrative services provided to all health plans underwritten or administered by health insurers who participate in the Health Insurance Marketplace, such as the claims administrative services Blue Cross provides to self-funded group health plans;

• Underwritten and self-funded group health plans that receive federal financial assistance, such as retiree plans that receive Medicare Retiree Drug subsidies or Employer Group Waiver Plan (EGWP) subsidies; and,

• Healthcare employers that receive federal financial assistance, such as hospitals and physician practices that receive payments from Medicare. If a healthcare employer also sponsors a group health plan, then that group health plan must also comply with Section 1557 because the healthcare employer receives such federal financial assistance.

Affordable Care Act – Health Programs and ActivitiesOn May 18, 2016, the Office for Civil Rights of the Department of Health and Human Services published Section 1557 of the Affordable Care Act. Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in health programs or activities that receive federal financial assistance. The following are notices about Section 1557 and Section 1557: Transgender Service Benefits.

However, the final rule does not require plans to cover any particular benefit or prohibit medical necessary determinations, so long as the plan operates in a nondiscriminatory manner.

Plans also cannot deny or limit otherwise covered benefits under the plan based on the gender in which the member is enrolled. For example, if a person is covered under the plan as a male but is diagnosed with ovarian cancer, then the plan cannot deny the otherwise covered services based on the fact that the person is a male.

Covered entities must make any required group health plan coverage changes effective on the first day of the plan year beginning on or after January 1, 2017.

Are self funded group employers that don’t receive federal financial assistance required to comply with Section 1557?HHS has stated that the final rule under Section 1557 of the ACA is based on established interpretations of the Civil Rights Act. Accordingly, if an employer’s self-funded group health plan benefits do not comply with Section 1557 and HHS does not have jurisdiction over that employer, HHS will refer that employer over to the Equal Employment Opportunity Commission (EEOC) for investigation under the Civil Rights Act.

Where can I go to learn more about Section 1557?Please visit the following websites to learn more about Section 1557 and how it impacts covered entities:

• For a copy of the final regulation, go to https://www.gpo.gov/fdsys/pkg/FR-2016-05-18/

pdf/2016-11458.pdf

• For a copy of OCR’s summary, go to http://www.hhs.gov/civil-rights/for-individuals/

section-1557/summary-of-final-rule/index.html

• For more on HHS training, go to http://www.hhs.gov/civil-rights/for-individuals/

section-1557/trainingmaterials/index.html

• For a copy of the model notice, taglines, and model nondiscrimination statement, go to

http://www.hhs.gov/civil-rights/for-individuals/section-1557/translated-resources/index.html

• For a list of the top 15 languages by state, go to https://www.cms.gov/CCIIO/Resources/

Regulations-and-Guidance/Downloads/Appendix-A-Top-15.pdf

Affordable Care Act – Transgender Services Benefit

Please find the following description of the Transgender Services Benefit to comply with Section 1557 of the Affordable Care Act, which will be posted on our website.

If the criteria are met, the following procedures are eligible for coverage:

A. Non-Surgical

1. HORMONE REPLACEMENT THERAPIES, including androgen blockers and gonadotropin-releasing (GnRh) analogs

2. LABORATORY TESTING, to monitor hormone therapy

B. Surgical

1. Female-to-Male

a. MASTECTOMY and CHEST WALL RECONSTRUCTION

*Note that a trial of hormone therapy is not a pre-requisite to qualifying for a mastectomy.

b. GONADECTOMYi. hysterectomyii. salpingo-oophorectomy

c. GENITAL RECONSTRUCTIVE SURGERYi. vaginectomyii. urethroplastyiii. metoidioplastyiv. phalloplastyv. scrotoplastyvi. placement of a testicular prosthesis and

erectile prosthesis2. Male-to-Female

a. BREAST DEVELOPMENT – female hormones for at least 12 months to achieve adequate breast development without surgery. Any further intervention by surgical means would be reviewed for medical necessity in accordance with medical policy #106 Reconstructive versus Cosmetic Surgery.

b. GONADECTOMYi. orchiectomy

c. GENITAL RECONSTRUCTIVE SURGERYi. penectomyii. vaginoplastyiii. labiaplasty, andiv. clitoroplasty

Effective 01/01/17, for TRANSGENDER BENEFITS:A member must meet ALL the following criteria established under the World Professional Association for Transgender Health (WPATH) (7th version) in order to be eligible:

1. Diagnosis of Gender Identity Disorder (ICD1 O F64.1); and

2. Age of majority (18 years of age or older); and

3. Have knowledge of the benefits and risks of surgery as demonstrated by and documented in an evaluation from a qualified mental health professional; and

4. Unless medically contraindicated, completion of twelve (12) months of continuous hormone therapy (EXCEPT for Mastectomy); and

5. Twelve continuous months of living in a congruent gender role with his/her gender identity (real life experience) prior to the gender reassignment services noted in the medical documentation (start/end dates included); and

6. If the member has significant medical or mental health issues present, they must be reasonably well controlled and noted in the medical documentation. If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (e.g., psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy prior to surgery and the effort(s) noted in the medical documentation; and

7. 2 referrals from qualified mental health professionals who have independently assessed the individual. 1 referral should be from a person who has only had an evaluative roll with the individual. Both referring providers must submit letters of their evaluation. (At least 1 of the evaluating professionals must have a doctoral degree [PhD, MD, Ed.B, D. Sc, D.S.W. or Psy.D] and be capable of adequately evaluating co-morbid psychiatric conditions.)

• Abdominoplasty

• Blepharoplasty (see also MP#064)

• Body contouring

• Breast augmentation, surgical (implants or autologous tissue flaps)

• Brow lift

• Calf implants

• Cheek/malar implants

• Chin/nose implants

• Collagen injections

• Construction of a clitoral hood

• Drugs for hair loss or growth

• Facial bone reduction

• Face lift/forehead lift

• Hair removal

• Hair transplantation

• Jaw shortening/sculpturing/facial bone reduction

• Lip reduction/lip enhancement

• Liposuction (see also MP#056)

• Mastopexy

• Neck tightening

• Pectoral implants

• Removal of redundant skin

• Rhinoplasty (see also MP#109)

• Skin resurfacing

• Thyroid chrondroplasty/trachea shave

• Voice modification surgery

• Voice therapy/voice lessons

The following services are considered COSMETIC in accordance with medical policy #106 Reconstructive versus Cosmetic Surgery, including but not limited to:

Is the Plan Underwritten or Self‐funded?

Underwritten  Self‐funded 

Is the group an  Applicable Large Employer (ALE)? 

Group has nothingto file.

Blue Cross filesForms 1094‐B and1095‐B to IRS andsends copy of Form1095‐B to member.

Group files Forms 1094‐Cand 1095‐C to IRS andsends copy of Form1095‐C to member.

Blue Cross files Forms1094‐B and 1095‐B to IRSand sends copy of Form1095‐B to member.

Group files Forms1094‐B and 1095‐Bto IRS and sendscopy of Form 1095‐Bto member. 

Blue Cross hasnothing to file.

Group files Forms1094‐C and 1095‐Cto IRS and sendscopy of Form 1095‐Cto member. 

Blue Cross hasnothing to file.

What is an ALE ? Employer has at least 50 full‐time employees, 

including full‐time equivalent employees, onaverage during the previous 

calendar year. 

Is the group an Applicable Large Employer (ALE)? 

Non‐ALE  ALE  Non‐ALE ALE

Responsibilities for 6055 and 6056 Reporting 

What can Blue Cross provide the group to assist with this reporting? A file that lists all individuals with an indicator for each month of the previous year to show if the individual did or did not have Minimum Essential Coverage (MEC). Groups are ultimately responsible for the accuracy of information reported to its employees and the IRS. Blue Cross cannot certify this data is complete and accurate for the group’s filing because we are not tax professionals. 

Blue Cross CANNOT determine the following for the group:  Was the plan deemed affordable by IRS rules for each employee? Was the plan offered to each employee?

Below is the timeline related to the release of the file we are providing as a courtesy on Group Access: 

Test report available

Production reports available

August-December 2016 

January  8, 2017January 15, 2017January 22, 2017 

* In order to guarantee enrollment updates will be reflected in the Final file, data will need to be sent toEnrollment by Friday, December 2.  However, if enrollment data is received after December 2, we willmake every effort to process Enrollment updates as quickly as possible prior to the Final file creation.

Each group must determine if they are an Applicable Large Employer (ALE) by seeking advice from their legal and tax professionals. 

  This will determine two things: 1. Who is responsible for the reporting.2. Which reporting forms to file.

Use the chart below to aid in understanding reporting responsibilities. 

What can Blue Cross provide the group to assist with this reporting?

A file that lists all individuals with an indicator for each month of the previous year to show if the individual did or did not have Minimum Essential Coverage (MEC). Groups are ultimately responsible for the accuracy of information reported to its employees and the IRS.Blue Cross cannot certify this data is complete and accurate for the group’s filing because we are nottax professionals.

Blue Cross CANNOT determine the following for the group:

• Was the plan deemed affordable by IRS rules for each employee?

• Was the plan offered to each employee?

Below is the timeline related to the release of the file we are providing as a courtesy on GroupAccess:

• Test report available August-December 2016

• Production reports available January 8, 2017 January 15, 2017 January 22, 2017

* In order to guarantee enrollment updates will be reflected in the final file, data will need to be sent to Enrollment by Friday, December 2. However, if enrollment data is received after December 2, we will make every effort to process enrollment updates as quickly as possible prior to the final file creation.

Determining 6055-6056 Reporting: Employer Shared Responsibility

PreventiveRequirement

Aspirin for the Prevention of Cardiovascular Disease Multiple Benefits Screening for High Blood

Pressure in Adults

Latent Tuberculosis Infection in Adults

Screening

Published Date

Existing recommendation with updated information published April 12, 2016

Existing recommendations with updated ICD10

(procedure and diagnosis), CPT & HCPCS coding

Existing recommendation with updated information

published October 13, 2015

New recommendation published

September 6, 2016

Blue CrossEffective Date

July 1, 2016 October 1, 2016 November 1, 2016 October 1, 2017

Change to Current Benefit?

YES: Age ranges changed for men from 45-79 yearsTO 50-59 years and for women from 13-79 yearsTO 13-59. Impacted members will be grandfathered through June 30, 2017. *New ranges effective 7/1/16 for new prescriptions due to other system updates effective same date.

YES: Applicable procedure and diagnosis coding updates (new/revised/deleted codes) to existing benefit services comprehensively reviewed and operationalized.

YES: Requires benefit in addition to screening in the medical office setting for confirmation of blood pressure measurements outside of the clinical setting before starting treatment.

YES: Requires benefit for screening testing. Population, test(s) and frequency parameters to be determined.

The new preventive care benefits will go into effect for all groups on the Blue Cross effective date. These new benefits are only applicable to non-grandfathered groups and grandfathered groups that cover mandated healthcare reform preventive services.

New Healthcare Reform Preventive Mandates

Reminder: Employer Payment Plans and Market Reforms

A new FAQ has been added about the Affordable Care Act as it pertains to employer payment plans and the individual market. As a reminder, employer healthcare arrangements that reimburse or directly pay the premium for individual coverage cannot satisfy market reforms. The consequence for doing so may be penalties, including excise taxes.

For more information, visit https://www.dol.gov/sites/default/files/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-33.pdf

BlueCard Worldwide Program Name Change

Effective January 1, 2017, the BlueCard Worldwide® Program name will change to Blue Cross Blue Shield Global Core. There will be no changes to the program itself, and no action is required on behalf of members.